Infectious Aneurysm Formation after Coronary Stent Implantation

Case Report | DOI: https://doi.org/10.31579/2692-9759/003

Infectious Aneurysm Formation after Coronary Stent Implantation

  • Khalida Soomro 1*
  • Muhammad Ali Soomro 2

1 Head of Department at Cardiology Dow University of Health Sciences
2 Sir Syed University of Engineering & Technology, Karachi, Pakistan

*Corresponding Author: Khalida Soomro, Head of Department at Cardiology Dow University of Health Sciences.

Citation: Soomro K, Muhammad A Soomro (2020) Infectious Aneurysm Formation after Coronary Stent Implantation. Journal of Cardiology Research and Reports, 2(1): 10.31579/2692-9759/003

Copyright: © 2020, Khalida Soomro, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Received: 20 February 2020 | Accepted: 02 March 2020 | Published: 04 March 2020

Keywords: coronary stent infections, complications/diagnosis/therapy, stents/adverse effects, staphylococcus aureus

Abstract

The formation of coronary artery aneurysm (CAA) is one of the critical complications after percutaneous coronary intervention (PCI). The most common aetiologies and aggravating factors for aneurysmal dilatation are acquired, such as atherosclerosis, Kawasaki disease, Takayasu disease, connective tissue disease, trauma after percutaneous coronary intervention (PCI) and infections. Cardiac catheterization itself carries a negligible bacteremic risk. We present the case of a patient who had infective coronary artery aneurysms that developed after PCI. A 63 years old male who had ST-T MI 1 month back and underwent primary percutaneous coronary intervention with deployment of 1 Des stent in Mid left anterior polymer-based paclitaxel-eluting stent 63 years having primary PCI for LAD 1 month back in the left anterior descending artery and A large aneurysm developed MID DES. The patient had C/O high grade fever only since 3 weeks remained asymptomatic then had angina at rest for 4 days. An aneurysm was diagnosed at middle of DES on repeat coronary angiography. Intravascular ultrasound demonstrated a true aneurysm about 5.6 mm in diameter. We will review the literature and discuss the causes specially infectious aneurysm and treatment option of aneurysm with stent usually detected at the time of repeat angiography for recurrent symptoms or as apart of the routine angiographic follow up [1].

Introduction

Formation of coronary aneurysm is a rare complication after implantation of bare metal stents (BMS), even in the drug-eluting stent (DES) era the incidence of such complication is still unknown [6, 7, 8, 9, and 10]. The prevalence of coronary artery aneurysms after PCI ranges from 0.2% to 10.5% [2, 3]. The true incidence, clinical course and treatment of coronary artery infectious aneurysm after stent implantation remain largely unknown as occurrence is very rare [4, 5]. As percutaneous coronary intervention has a greater bacteremic potential, presumably due to the prolonged procedural time and the repeated insertion of interventional devices into the vascular system, in apparent bacteraemia occurs frequently (in approximately 30% of cases) after complex percutaneous coronary intervention (PCI); however, clinical sequelae of aneurysm formation rarely occurs. When this septic complication occurs after PCI, morbidity and death often result. [11] Early evaluation is necessary to avoid complications. Dieter’s criteria are often helpful for diagnosis. Such criteria which should have been present either placement of a coronary stent within the previous 4 weeks,h/o multiple repeated procedures performed through the same arterial sheath, presence of bacteremia, significant fever, or leucocytosis with no other cause; H/O acute coronary syndrome,or positive cardiac imaging. Definitive diagnosis is made by autopsy or examination of surgical material here [12, 13]. We are presenting the case of a patient having  infective coronary artery aneurysm diagnosed 4 weeks after PCI,  to review of literature the possible contributing causes and diagnostic factors.

Case Report
A 65 -year-old male with a history of hypertension, hypercholesterolemia and diabetes mellitus admitted with diagnosis of acute coronary syndrome with ST-segment elevation in Anterior Leads of EKG, The following drugs were administered in the emergency department: Aspirin, 300 mg; tricagrelor 180 mg; Atorvastatin 40 mg laboratory tests were performed, His Blood pressure was 160/100 mmHg and pulse 58/min, regular. Blood chemistry showed total cholesterol  250mg/dl, triglyceride 365mg/dl, high-density lipoprotein cholesterol 28 mg/dl, and LDL-C 170 mg/dl, fasting blood sugar 140g/dl, HbA1c 7.8% under the medication. An Echocardiogram in ER revealed left ventricular end-diastolic dimension of 54mm, Ejection fraction 45% and mild left ventricular hypertrophy. Basal, mid segment of IVS and apex wall segment showed hypo-kinesis while in rest of the segments of LV normal contraction noticed. The patient was taken to the catheterization laboratory

Figure 1

Coronary angiography revealed severe stenosis at the middle portion of the Left Anterior descending Artery (LAD) (Fig. 1A). Lesion was successfully opened and 1 drug eluting stents (Taxus, 3.5 X28 mm) was deployed sequentially after intravascular ultrasound assessment with maximum inflation pressures 14, 12, and 16 ATM respectively (Figures 1B).
He denied any discomfort after the deployment of DES. 4 weeks later he presented with recurrent fever, chills, a persistent dry cough and unstable angina 4 days duration in ER. The presumptive diagnoses on admission were chest infection and acute coronary syndrome.
On admission were chest infection and acute coronary syndrome.

Figure 2

EKG Showed Q-wave with T-wave inversion in the anterior lead (figure 2A) mean while blood culture and other lab test were sent. X-RAY chest was unremarkable.

After 45 min of hospital delay, patient underwent repeat coronary angiography showed no significant stenosis in the right coronary, main left coronary and circumflex arteries but shows LAD eccentric secular aneurysm with tight stent re-stenosis (90% stenosis) at the junction of mid to distal segment at the site of DES implanted 4 weeks back. {Figure 3A}
Assessment of the aneurysmal area using intravascular ultrasound (IVUS, 40 MHz, Boston Scientific Scimed) demonstrated a true aneurysm about 6.5 mm in diameter. Intravenous unfractionated heparin (100 unit/kg) was administered.

Figure 3

 

A 0.014 floppy guide wire was positioned in the distal portion of the left anterior descending (LAD) artery through the occlusion. Then, pre-dilation was performed with a 2.5 × 20 mm balloon catheter inflated to 10 ATM and a 275.0 × 24 mm PTEF stent deployed at 10 atm. A good result of the implanted stent was observed on the control coronary angiography, image (3-C).

Admission blood cultures grew methicillin-resistant Staphylococcus aureus (MRSA). (Table-1)

Laboratory Tests

Table 1

Relevant therapy Intravenous vancomycin and gentamicin continued .The patient improved clinically. At the 6-month follow-up, he was asymptomatic, performing his activities of daily living normally, and taking the medications prescribed at hospital discharge.

Discussion

Coronary Artery aneurysm after coronary intervention are rare.[14] According to a study ,the actual incidence of coronary arterial aneurysm (CAA) formation after Stents implantation is not yet thoroughly surveyed,[15]  yet available data shows incidence of 3.9 to 5% after PCI with stents and up to 10% from  directional coronary atherectomy. Residual dissection and deep arterial  wall injury (rupture or resection of the vessel media) caused by oversized balloons or stents, high-pressure balloons inflations, atherectomy, and laser angioplasty have all been associated with coronary artery aneurysms after coronary intervention. In addition to mechanical risk factor observed for the aneurysm formation with both BMS and DES ,other potential mechanism are also related and Specific to Drug-eluting stents (DES) [16,17,18,19] , although inflammatory and allergic reaction to Nickle and molybdenum have been reported after BMS implantation triggers for inflammatory and allergic reaction after DES implantation are more complex which locally elute anti-proliferative drugs, these can dramatically inhibit neointimal growth , thereby suppressing re-stenosis [20] , DES at the same time potentially cause coronary aneurysms due to other mechanisms alsoDES consists of 3 components the antirestenotic drug ,the drug carer vehicle polymer and stent platform ,in particular the polymer carrier has been shown to provoke eosinophilic /heterophilic infiltration and marked inflammatory reaction of the arterial wall with extensive inflammation consisting of eosinophils and lymphocytes and  focal giant cell reaction around the stents struts ,surrounding the polymer after DES implantation. In addition, delayed healing reaction in response to DES such as incomplete endothelialisation over struts have been detected by invasive approaches (angioscopy and optical co-herence tomography) as well as autopsy studies [21]. In short the combination of physical trauma induced by stent implantation and specific biological reactions after DES implantation might together contribute to coronary aneurysm formation after DES implantation and can lead to type 1 aneurysms that demonstrates rapid early growth with pseudo aneurysm formation detected within 4 weeks and arterial injury related procedure is also likely contributor to this type of aneurysm formation [22] And typically complicated by clinical pericarditis [23].

Type 1

Second type of aneurysm is typically detected incidently during angiography for recurrent symptoms or as a part of protocol mediated angiography follow up (usually detected >6 months duration after the procedure and have most varied presentations [24]. Specially some complains of angina, seems more likely in this scenario that a chronic arterial response to a metal stent, polymer and drug may be basis for aneurysm in this sub type of aneurysm [25]. Our case was having infectious aetiology (type 3) these patients typically present with systemic manifestation and high grade fever as the result of bacteraemia [26, 27]. Whether the local immunosuppressive effects of Eluted drugs from stents tend to increase the incidence of these rare

Infectious aneurysms or multiple risk factors for infections after PCI could have been suspected [28, 29]. Evans and Goldstein noted that any of these events—repeat PCI with re-puncture of the ipsilateral femoral artery within 3 to 7 days of the initial procedure, access site hematoma, or skin drainage—increased the peri -procedural risk of infection to 30%. It has been suggested that small soft-tissue hematomas may impair local host defence mechanisms. McCready and co-authors described re-puncture of the ipsilateral artery and indwelling of the vascular sheath for more than 24 hours after the procedure as major risk factors for post-PCI septic complications. Other predisposing factors may include duration of the procedure, number of passages of the catheters through the femoral sheath, bleeding at the puncture site, and pseudo-aneurysm [30, 31, and 32]. In our patient had none of these risk factors were clearly operative .Staphylococcus aureus and Pseudomonas aeruginosa seem to be the most frequently infective organisms in infected aneurysms [33,34,35,36]. In  large infected aneurysms after DES or BMS implantation, Staphylococcus Aureus has been reported as cause of Coronary infection after stenting can present days to weeks after intervention most frequently as an acute coronary syndrome [36,37]. Other complications include thrombosis, distal embolization, and rupture. Evaluation of infection consists of positive blood cultures which are diagnostic of a serious infection but they do not identify the anatomic source of the infection. A radiolabelled leukocyte scan can early confirm the diagnosis [12]. Although angiography remains the gold standard for diagnosis, coronary aneurysms can also be detected by transesophageal echocardiography, contrast-enhanced computed tomography, and magnetic resonance imaging and IVUS [22,25] Aneurysms more than 1 to 2 cm in diameter are unlikely to resolve and they may enlarge and eventually rupture even when the lesions have been sterilized with antibiotics. The frequency of these complications is difficult to determine, because of the extremely low prevalence and lack of published data on coronary artery aneurysms secondary to stent implantation and the absence of natural history data of untreated coronary aneurysms, after stents treatment gives dilemma of treatment on individualized basis on case by case best clinical judgment decision as the treatment for infectious coronary aneurysms is not clear-cut.

Broad spectrum antibiotic therapy and surgical intervention includes stent removal, should be ideal strategy and depends on coronary angio findings. The PCI using PTFE or autologous venous covered stent, the surgical repair with CABG or conservative management under continuing dual-antiplatelet therapy and proper antibiotic therapy are supposed to be considerable strategy. what complicates the clinical decision making process further is the fact that complete resolution of these aneurysms has been observed in some cases without specific treatment ,in contrast to the possibility of rupture if the aneurysm is left untreated [11]. If CAA is small and may have a lower risk for rupture, and conservative management will be more appropriate [32]. As in our case was performed .Covered (polytetrafluoroethylene (PTFE), saphenous vein or papyrus) with spring release inside the aneurysm are the most frequently percutaneous techniques to treat aneurysm [7, 11]. Coil is implanted using a technique that, although aimed only at thrombosis of aneurysms, is technically challenging and associated with risks [1, 20].Surgery should be considered for patients with large aneurysms because of the high risk of rupture. Surgical revascularization procedures include saphenous vein grafting alone or in combination with aneurysm resection [36].

Conclusion

In our patient, the occurrence of bacteremia shortly after coronary artery intervention suggests a causal effect of the procedure on the formation of the aneurysm. however the source was not determined .learning point here is this is one of the rare complication which should come into the mind of cardiologist if patient have fever after stenting, further investigations is necessary to determine the pathophysiology .natural historyand best therapy forinfectious aneurysms .although difficult to prove which is only possible on the examination of the surgical material of autopsy.

References

Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.

img

Virginia E. Koenig

Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.

img

Delcio G Silva Junior

Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.

img

Ziemlé Clément Méda

Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.

img

Mina Sherif Soliman Georgy

We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.

img

Layla Shojaie

The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.

img

Sing-yung Wu

Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.

img

Orlando Villarreal

Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.

img

Katarzyna Byczkowska

Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.

img

Anthony Kodzo-Grey Venyo

Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.

img

Pedro Marques Gomes

Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.

img

Bernard Terkimbi Utoo

This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.

img

Prof Sherif W Mansour

Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.

img

Hao Jiang

As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.

img

Dr Shiming Tang

Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.

img

Raed Mualem

International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.

img

Andreas Filippaios

Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.

img

Dr Suramya Dhamija

Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.

img

Bruno Chauffert

I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!

img

Baheci Selen

"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".

img

Jesus Simal-Gandara

I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.

img

Douglas Miyazaki

We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.

img

Dr Griffith

I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.

img

Dr Tong Ming Liu

I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.

img

Husain Taha Radhi

I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.

img

S Munshi

Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.

img

Tania Munoz

“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.

img

George Varvatsoulias

Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.

img

Rui Tao

Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.

img

Khurram Arshad